relationships and conversations that make a difference

Each issue of the Journal will pose a Frequently Asked Question for reflection–discussion. The emphasis is on the notion that questions are posed as starting points for dialogue and not for answers. In the spirit of the Journal as a format for interchange, there will be multiple conversation-initiators for each question. Reflections–discussions are first presented in English, followed by the Spanish translation. Readers are invited to post their responses. Readers are also invited to pose questions for the FAQ section of future issues of the Journal. (To post, please scroll to the end of the page to the “Comment” box.)

There are very different understandings of “not-knowing” among the practitioners and students that I meet. As I understand it, the concept can be defined as a position one takes up in a therapeutic conversation in which the attitude is “I cannot know what your experiences have meant for you in your life, or which position you take in relation to these events today, before you have tried to tell me about this.” Some practitioners are indifferent to the concept and feel it is unnecessary; some mock it, others do not understand it, some love it and cultivate it, while others view it as appropriate and unproblematic.

In my experience and understanding, I take-for-granted that I cannot know about the other and their experiences: Its power resides in the client’s surprise of being met with such an attitude. Its power also resides in the opportunity for the other person to be curious about themselves. Taking-for-granted that we will never be able to know anything about another is an exciting and challenging thought. I cannot know what another person’s experiences have meant for them. I cannot know the position the other takes in relation to that which has been experienced and expressed. My prior understanding permeates my wandering in the landscape of the other’s experience while the challenge is not to allow myself to be held captive by it. I continually must gaze up, down, under, to the side, in the shadow of, behind, in front and up ahead to learn about the other and their lived experience-not my interpretation of it.

The surprise is that we are seldom met in our professional, or personal, lives with a “not-knowing position.” Those who ask the questions, the professional helpers, are often people who for different reasons wish the other well. They want to understand the other. Perhaps they want to understand too quickly. Perhaps they want to show recognition through understanding, that they appreciate the suffering, the misery, the experience of what has been narrated. We often believe that we know what is best for the other, and that we understand without actually understanding. Many times I have said and heard the expressions “I understand what you mean”, “I understand how it is for you”. At the same time, the client knows that the other, the professional, does not have enough information to understand and the next question can reveal that the professional has not understood, cannot know. Often it is not even necessary for the professional to understand. Understanding, like interpretation, is a joint activity that occurs in the dialogue between therapist and client and, though of course influenced by, it is not solely a result of preconceived theories or narratives, expertise, experience or therapeutic models.

Sylvia LondonGrupo Campos Eliseos
Mexico City, Mexico

The not-knowing stance reflects a belief that a therapist, consultant, teacher or coach is not capable of knowing what is the best answer or idea for another person. It does not mean that you do not know anything. On the contrary, it invites you to offer your ideas, as many as possible, carefully and tentatively allowing the other person to think with, or without you, about the relevance each utterance has in his or her own life. Uncertainty, curiosity, humbleness and creativity naturally flow from the not-knowing position.

Not-knowing is likely the most provocative and misunderstood concept that Harry Goolishian and I introduced into the psychotherapy literature. Perhaps it provokes because it challenges our epistemological foundations and it invites discrepant translations of our narratives, experiences, and beliefs as we each bring our own understandings to our interpretations of the familiar and the unfamiliar.

Not-knowing is as much about what we think we know as it is about what we do not know. It has to do with the intent and manner with which we position ourselves, approach, introduce, and use knowledge as Randi Bagge has mentioned above. Not-knowing is critical to the dialogical process. Offering knowledge–whether in the form of a question, a comment, a suggestion, etc-is a way of participating in a generative conversation that leads to newness and possibilities, or as Wittgenstein suggests, knowing how to “go on” with each other. It is offered to facilitate the conversation, and as Norwegian psychiatrist Tom Andersen has said, to help people talk with themselves and with each other in a way that they have not been able to do before. In other words, the focus is on the process of the conversation more so than its content. Not-knowing requires us to offer our utterances in a tentative manner, to not expect that the other will accept or agree with them, and to be open to being challenged. I want to emphasize what Sylvia London suggests above: not-knowing involves uncertainty: As we make our way with the other, in dialogue, we are ever spontaneously responsive and therefore we are not in control of the outcome. As well, we are ever open to the surprises of our jointly creating ways to go on.

21 Responses

The concept of “not knowing” is an extremely interesting one in the context of graduate medical education (in which I practice). A posture of uncertainty and curiosity are essential elements of the “not knowing” position in relational practice. This is antithetical to the entire culture of medical education and the overarching Western culture of healthcare delivery and medicine. Consequently, when I introduce this concept and invite physicians to consider it in light of their conversations with their patients; I encounter reactions ranging from mild interest to outright oppositions and rejection!

I’d be interested in other’s reflections on “not knowing” in the medical subculture. How have others engaged physicians in this? From a patient or consumer perspective? From an educational and consultive perspective?

I am sometimes challenged by couples who return to therapy – many months or a year or two after our initial work ended. They found that in the long run, the collaborative effort had been too hard to hang onto in the moments of anguish in their marriage. We review and re-experience the care and mutuality of dialogue, and often they walk away boosted in their skills, but, I think, less assured.

I am interested in how others here think about “setting” collaborative skills more effectively with those they work with? I have found a similar wearing off effect in the long term outcome of my work with corporate groups – the culture changes and is working very well, but then, over time, it seems to be lost.

I recently had a conversation about not-knowing with my daughter-in-law who has had three years in her training to be a medical doctor. She did not see much of that attitude in the clinical work she had experienced so far, and she was curious about my view on the relevance of that position within the medical field. She expected that both patients, and most of all her clinical supervisors, expected a position of knowledge and certainty, yet she had seen that the most creative people she had met in her training, had a curiosity and openness in front of clinical challenges that she could identify as not-knowing. And she had seen some very inadequate conversations where the effect of the “knowing” had been disrespect for the situation of the patient at the time. She found the perspective very interesting and wanted to return to the subject. I think back on our talk, amazed that I, as mother-in-law, had the privilege to engage in her question.

As I enter this conversation, I experience most comments and questions as generated from a position critical of the power hungry practitioner; but I wonder what you say to the “client” or “patient” who asks some version of the following: “Why should we spend our time and money in dialog with someone who takes a position of not-knowing more than we do? We come to you precisely BECAUSE we believe you DO know more than we do.”

Paul Dell once explained in one of his classes years ago that of the infinite possible outcomes we might “know” is right for any given client, we are 99.9% likely to miss the exact right one, and will have wasted the client’s money and time. Engaging with the client in a process of mutual inquiry, in a collaborative conversational format, assures a greater likelihood of arriving at a satisfying outcome for the client.

Rodney,
I think you raise a very important question, I often wonder about it myself. Earlier in my career, when I first came in contact with collaborative ideas, I thought that I was not suppossed to share or offer any knowledge other than what came from the clients.I think that was a misuderstanding on my part.Now I see things differently, I am happy to share what I know with clients, but I try to do it in a way that puts that information “on the table”, as Harlene Anderson says “food for thought and dialogue”, not as the last word or the only possible explanation or path to follow. Harlene has also taught me that “you can talk about anything, what is important is how you talk about it”. Now I feel much freer to bring into the conversation information from the areas I am most knowledeable about and I think clients often appreciate it if it is useful input for their situation.
Margarita

Kate (spousal unit) is a family practice doctor and quite the contrary to your experience finds coming from a participatory stance very frustrating because “most patients” are only too willing to abdicate responsibility and power in return for an”answer” from the “expert”.

This is, only in part, why I posed the question above. There are clients/patients who are put off by a collaborative approach; unless you come off as all-knowing, they worry that you know nothing at all.

I think there are important differences between medicine and therapy and that in the case of medicine there is much more room for the doctor’s expert knowledge. The way I see it, when in therapy we say that the client is the expert, we are talking about the client’s knowledge of their experience, of what they think feel,perceive and what it means to them and in that case they truly are the ones who know most about those realms.
In the case of medicine, a person may know that they feel dizy and faint and irritable,but may not know about fluctuations in glucose levels, for example and the doctor’s knowledge about this may be crucial for their cure or relief.

That said, I have had some TERRIBLE experiences with world renown doctos who simply did not listen to the patient (my family member), did not take the patient’s experience seriously and jumped to conclussions or “knew” too soon. This had serious and very painful medical consequences, it goes beyong simple “bedside manners”. In sum, I think that medical doctors can benefit from the “not lnowing” position in the sense of not knowing too soon listening carefully and taking the patients own knowledge of their body seriously, and offering their own expert knowledge about medical matters.
Margarita

Of course you make good points here. I would just add that when I mention patients who are only too willing to abdicate responsibility and power in return for an”answer” from the “expert”, I am talking about situations where there is no clear cut or “right” answer.

Like in therapy, much of medicine (especially primary care medicine) is about feelings, perceptions and values. What is medically indicated in “the valiant struggle to defeat death” may contradict the patient’s subjective experience of what constitutes a good life. Kate has had several patients say they don’t want to enroll in heroic measures for their cancer. They want to go into a hospice program and they want a docotr who believes in effective pain relief and they want to go when their time comes. This is something difficult for some doctors to accept. I think one reason Kate’s practice is so busy is that she is willing, not matter how personally frustrating, to listen to what is important to the patient.

Rodney

P.S. On your last point, years ago when I worked as a nursing assistant, I used ask patients and family members if they really understood what the bedside doctor had just said. Suddenly, their heads would stop shaking in concurrence and switch to the “no” sign. I would also ask if there was anything they needed to ask to better understand. It wasn’t really “my job” and not all of the doctors appreciated it but I felt this was a job that needed to be done because patients can be overwhelmed and intimidated by the white coat and the technical vocabulary.

I understand what Kate is offering about some patients wanting an expert opinion from their doctor and I have experienced the same thing from clients in therapy at times. I respect people’s desire for “an answer” to what are really unanswerable questions. I experience this as their inviting me to help them deal with the uncertainty of their diagnosis, condition , symtoms, dilemma etc. How I responsd to their invitation is ripe with possibilities. If someone persists and asks me – or a doctor – to make a statement about “what to do about (whatever)”, I respond with my take on things and counsel the residents I train to respond with the best evidenced based answer they can give. I further counsel that they frame their answer as just that – their best possible opinion based upon the evidence that they are aware of.

All human beings possess a continuum of knowledge about subjects. That continuum ranges from little to no experience with a subject to a great deal of experience with a particular subject. For example, although my Family Practice Doctor has far more experience with diagnosing an infected ear, I have some limited experience of my own with it . I know what it feels like to me. Together we can pool our knowledge and arrive at a diagnosis. I need his or her expertise along with my presenting the experience of the symptoms to arrive at a diagnosis and treatment with the greatest probability of successful outcome.

One last thing before I close on my long winded response :-)…….My husband recently completed a long and arduous course of treatment for a pretty rare cancer. His oncologist was incredibly collaborative with both of us all along the journey. Oncologists are notorious for taking an expert posture and their patients are eager for them to do so as they are usually coming from an anxious and fearful position. We although crave something to hang on to when we’re adrift in a sea of uncertainty. My husband and I relied very heavily on the wonderful expertise of the oncologist AND we were active collaboratives with him as well.

I recently had a conversation about not-knowing with my daughter-in-law who has had three years in her training to be a medical doctor. She did not see much of that attitude in the clinical work she had experienced so far, and she was curious about my view on the relevance of that position within the medical field. She expected that both patients, and most of all her clinical supervisors, expected a position of knowledge and certainty, yet she had seen that the most creative people she had met in her training, had a curiosity and openness in front of clinical challenges that she could identify as not-knowing. And she had seen some very inadequate conversations where the effect of the “knowing” had been disrespect for the situation of the patient at the time. She found the perspective very interesting and wanted to return to the subject. I think back on our talk, amazed that I, as mother-in-law, had the privilege to engage in her question.
+1

I, too am coming into my own understanding of “not-knowing”. Phrases and a humble tone of voice can convey the curiously that comes when developing a mutual conversation. Prhases like, “I’m not sure I got what you told me is it…? “I think I see what you’re saying but I need to check it out with you. Help me here.” “What do you think about when…?” The tone of voice that joins the phrases are humble, tenititve, and even somewhat hesitate in delivery. Sincerely wanting to know what we don’t know helps us not become a know it all. The result: a process of collaborative conversation.

I, too am coming into my understanding of “not-knowing”. Phrases (incomplete sentences) and sentences plus a humble tone of voice can convey the curiousity that comes when developing a shared inquiry. Phrases like, “I’m not sure I got what you told me…”, “I think I see what you’re saying but I need to check it out. Help me out here.”, “What is it you’re wanting me to know ?
The tone of voice which join the phrases and sentences are humble, tentative and even somewhat hesitate in delivery. This attitude could also apply to one’s tone of “face” and body language.
Sincerely wanting to know what we don’t know helps us not become a know-it-all.
The result: a process of collaborative conversation.

I am coming to understand that you can be an expert and still come to an encounter from “not-knowing” because these two places of knowing are different. You might be an expert oncologist (to borrow Wendy’s example) and know what is best for the patient from a medical interventionist perspective but that does not qualify you to know what is best for the whole person from a moral, values, spiritual, familial, relational perspective. To believe you are the expert on what is best for the patient in all areas assumes that the medical model is superior to any other consideration. Such a view turns all potential dialog into hegemonic monolog and invalidates the patient as a whole person.

I have come to the belief that in knowing you frequently miss those critical variables that you don’t know, especially when they exist in the blank space of knowledge that you don’t know, you don’t know.

As I apply problem solving methodologies, what I know is a mechanism for stepwise analysis, which tools to use when, why they should be used and how and when to use them. This then is applied to the client’s known problem or opportunity. Then it becomes a process of following the data to solution, unfettered by what you already believe you and the client know about the problem, its causes and its probable best case solutions.

Similarly, when applying strengths-based approaches such as Appreciative Inquiry, while the methodology seems a bit more open, flexible and situationally driven, there still exists a process in which the expert / practitioner follows a path in helping those that know, to understand better what they know and how to build upon it and make it the norm.

So, perhaps it’s valid to look at expertise such as medicine, counseling, management consulting, business process improvement, etc., as developing methodological templates actioned with situationally driven tools usage, which can then overlay and manipulate the client’s known, to aid in sense-making and betterment.